878 CHEMOTHERAPY AUG. 1993

Low dose intravenous infusion of amphotericin B for prevention of

fungal infection in patients with acute leukemia

Akihiro Takeshita, Kaori Shinjo, Sadahiro Tamashima,

and Ryuzo Ohno

Third Department of Internal Medicine, Hamamatsu University School of Medicine,

3600 Handa-cho Hamamatsu-shi, 431-31, Japan

(Received March 29, 1993•EAccepted May 7, 1993)

The effect of amphotericin B (AMPH) on the prevention of fungal infection in twenty-

eight patients with acute myeloblastic leukemia (AML) was studied. The patients

received a BHAC-DP regimen as consolidation and intensification chemotherapy; Enoci-

tabin (BH-AC) 250mg/day for 7 days, Daunorubicin (DNR) 40mg/day for 3 days, and

Prednisolone (PSL) 30mg/day for 7 days. Intravenous infusion (i. v.) of AMPH (0.15

mg/kg/day) was dosed, in addition to oral administration of AMPH (2,400mg/day), in

41 treatment periods in patients with AML (i. v. infusion group). Oral AMPH alone was

administered, in 38 treatment periods, to patients with AML (oral administration group).

The period of apyrexia, the period of fever, C reactive protein (CRP), erythrocyte

sedimentation rate (ESR), culture data, incidence of adverse effects, and the quantity of

endotoxin were compared between the two groups. The ENT. infusion group showed

signififcantly better results than the oral administration group; the period of fever was

significantly shorter (2.7 •} 3.5 days, p < 0.05), and serious systemic fungal infection was

less offen detected (0 cases) than in the oral administration group (3 cases). No serious

adverse events were observed.

Key words: Amphotericin B, Prevention of fungal infection, Leukemia,,8-glucan

Introduction

Patients with acute leukemia who become granu-

locytopenic during and after chemotherapy are

prone to many bacterial and fungal infections1.2).These infections are the cause of death in some

patients, and reflect their prognosis. In patientswith leukemia, once they develop a fungal infec-

tion, it is very difficult to achieve a complete cure

because of prolonged granulocytopenia, immunode-

ficiency, and mucosal injury induced by antitumor

agents3) The prevention of infections therefore

remains extremely important in these patients.

Advances in antibiotics and antifungal agents and

development of various hemopoietic factors has led

to a gradual decrease in these complications.

AMPH is one of the most effective antifungal

agents with respect to its spectrum and potency.

Oral administration of AMPH for the prevention of

fungal infections in patients with acute leukemia

has been reported in many centers4-6). However in

severely granulocytopenic patients with hematolo-

gic disorders, not all types of fungal infections can

be prevented7) Intravenous infusion of AMPH is

useful, but its adverse effects of fever, hypokalemia

and renal toxicity, for example, are potentially

serious problems associated with its use. Various

methods of administering this drug to decrease its

toxicity have been described8•`11). We used a low

dose (maintenance dosage, 0.15mg/kg/day) i.v.

infusion of AMPH in patients with acute leukemia,

and discuss the utility of this regimen for the preven-

tion of fungal infection in these patients.

VOL. 41 NO. 8 Prophylactic Use of Intravenous Amphotericin B in AML 879

Patients and methods

Background of patientsTwenty-eight patients with acute myeloblastic

leukemia (AML) admitted to the hospital of the

Hamamatsu University School of Medicine from

January 1986 to January 1992 were studied. Theywere treated with a BHAC-DP regimen, composed

of BHAC 250mg (day 1-7), DNR 40mg (day 1-

3), and PSL 30mg (day 1-7) in a laminar air flowroom, as consolidation and intensification therapies

(Fig. 1). We analysed a total of 79 treatment

periods in 28 patients. Patients with other types ofleukemia and those receiving remission induction

therapy were excluded from this study because ofvariations in their chemotherapy regimens. On

admission for chemotherapy, the treatment periodswere randomized to either (1) oral administration of

AMPH (2,400mg/day) or (2) oral administration

and i.v. infusion of AMPH (2,400mg/day and

0.15mg/kg/day, respectively) for prevention offungal infections. The former treatment periodsnumbered 41, the latter 38. The cases were allocat-

ed to one of the two administration groups by the

blind envelope method in each of 79 courses. Nosignificant differences were observed between the

two administration groups in sex, age, WBC countat nadir, and CRP value before the administration

of AMPH (Table 1) All patients were given poly-

mixin B (300 •~ 104 U/day) and sulfamethoxazole-

trimethoprim (ST) (1,200mg and 2,400mg/day,

respectively) for intestinal decontamination, but

recombinant human granulocyte colony stimulating

factor (rhG-CSF) was not administered. All of the

patients had pancytopenia with circulating granu-

locyte counts of less than 500/ƒÊl, and were at risk

of bacterial and fungal infections. The patients who

had obvious bacterial infections (ex sepsis) were

excluded.

Administration method of AMPH

For the i.v. infusion technique, AMPH was start-

ed at a daily infusion dose of 1mg/day, and gradu-

ally escalated in 1mg/day increments to reach a

maintenance dose of 0.15mg/day. AMPH was in-

fused over 6 hours once a day in 250ml of a 5%

glucose solution.

Evaluation of the effect of the therapy

Evaluation of the therapy was performed using

the following data; maximum value of CRP, the

period during which the CRP value was greater than

1mg/dl, the period of apyrexia after chemother-

apy, the period of fever, the periods during which

ESR was greater than 30 and 50mm/h, the posi-

tivity of fungal cultures sampled from the pharynx,

sputum, urine, stool, and blood, and endotoxin

Fig. 1. Details of administration of the BHAC-DP regimen.

Table 1. Details of patients (age, sex, WBC count in nadir and CRP value

before the administration of amphotericin B)

11 Statistically different from the oral administration group, (p<0.05)

880 CHEMOTHERAPY AUG. 1993

measurements. Adverse effects of therapy were

monitored by creatinine clearance, fever, serum

electrolytes, skin eruption and other clinical signs.

Serum was sampled before administration of

AMPH, and once every two days.

Measurement of serum concentration of AMPH

Serum concentrations of AMPH were determined

in some patients. In the i, v. infusion group (n=

12), serum samples were collected at minimum

before (trough) and immediately after (peak)

each infusion. Sera were also collected ten days

after administration from patients in the oral ad-

ministration group (n=10). The AMPH concentra-

tion was measured by bioassay1,2).

Endotoxin test

Endotoxins were also studied to analyze the inci-

dence of fungal infection. We analyzed three en-

dotoxin parameters including the Toxicolor Test

(T-test), Endospecy Test (E-test) and ƒÀ-glucan.

An antitumor carboxymethylated -ƒÀ-glucan

(CMPS), a component of the fungal cell wall,

correlates with fungal infection. The amount of,ƒÀ-

glucan in plasma was estimated by subtracting the

E-test results from those of the T-test. Plasma was

sampled before administration of AMPH, during

the febrile periods, and 10 days after the end of

chemotherapy. Data were compared between the

oral administration and i. v. infusion groupim,

Differences between the two groups were analysed

with Student's non-paired T test.

Results

The results of maximum CRP value, the period

during which CRP was greater than 1mg/dl, the

period of apyrexia after chemotherapy, the period

of fever, the periods during which ESR was greater

than 30 and 50mm/h, and the positivity of fungal

cultures sampled from the pharynx, sputum, urine,

stool, and blood were compared between the oral

administration group and the i, v. infusion group

(Table 2). The periods of fever greater than 37.5•Ž

were 4.8•}4.3 days and 2.7 •} 3.5 days, respective-

ly, significantly shorter days (P<0.05) in the i.v.

infusion group. The maximum CRP values were

7.8 •} 7.3 and 4.8 •}4.1mg/dl, respectively, with a

signififcantly lower value in the i. v. infusion group

than in the oral administration group (P<0.05)

No significant differences were observed in the

other parameters.

The results of fungal cultures are summarized in

Tables 3 and 4. If at least one sample culture from

Table 2. Period of fever, period of apyrexia, CRP and ESR values in the

oral administration and i.v. infusion groups (mean•}S. D.)

* Statistically different from the oral administration group, (p<0.05)

VOL.41 NO.8 Prophylactic Use of Intravenous Amphotericin B in AML 881

Table 3. Results of fungal cultures in patients in the iv. infusion (n=41) and

oral administration groups (n=38)

* Statistically different from oral administration group, (p<0.05)

Table 4, Detailed results of fungal cultures in the i.v. infusion (n=4/41) and

oral administration groups (n=11/41)

AMPH, amphotericin B.

the pharynx, sputum, urine, stool, or blood was

positive, the case was judged as positive. The rateof positivity in the i . v. infusion group was 9.6%,

while that in the oral administration group was

28.9%. Candida albicans was the most frequently

detected fungus, while Aspergillus species were

detected in two cases of the oral administration

group, but none in the i.v. infusion group. Funguswas detected on blood cultures in two cases in the

oral administration group, but none in the LI/.

infusion group.

The adverse effects considered to be induced by

AMPH in the i.v. infusion group are summarized in

Table 5. Drug eruption was seen in two cases,

while hypokalemia and mild renal dysfunction were

seen in one each. No other adverse effects, such as

liver dysfunction and fever, were observed in this

study. No adverse effects were observed in the oral

administration group except for mild nausea.

AMPH concentrations in blood were measured.

The peak blood concentration of AMPH in the i. v.

infusion group was 0.80 •} 0.38 pg/m1 (n=10), and

the trough was 0.17 •} 0.08 ,ug/ml (n=10). The

concentration in the oral administration group was

0.11•}0.09 /./g/m1 (n=10).

The data on endotoxin changes are shown in

Table 6. Values obtained by subtracting E-test

from T-test results, which correlate with fi- D-

glucan , were significantly lower (1.0 •} 1.6 pg/ml)

in the i.v. infusion group than in the oral adminis-

882 CHEMOTHERAPY AUG. 1993

Table 5. Details and incidence of adverse events in the iv. infusion group (n=14)

AMPH, amphotericin B.

Table 6. Endotoxin levels before and after administration of amphotericin B in the

oral administration group and i.v infusion group (meantS. D.)

Oral administration group (n=38)

Intravenous infusion group (n=41)

* Statistically different from oral administration group (p<0 .05)

tration group (7.5•}11.6 pg/ml) (p < 0.05) during

the febrile periods. The difference in value between

the febrile period and before AMPH administration

was significantly lower (0.7 •} 6.8 pg/ml) in the i.

v. infusion group than in the oral administration

group (6.8 •} 11.2 pg/ml) (p < 0.05) . Other endoto-

xin indexes, such as T-test and E-test results

alone, showed no significant difference.

Discussion

Fungal infection is one of the most significant

problems experienced by patients with hematologic

malignancies, especially acute leukemia. Immuno-

deficiency, mucosal injury, catheterization, granu-

locytopenia , and the administration of broad spec-

trum antibacterial agents are associated with in-

creased frequency and severity of fungal infec-

tionsl.4.15). Oral antifungal prophylaxis has been

tried in many centers, but sufficient effect has not

been achieved in systemic infection'". Many cen-

ters, including our hospital, have tested oral admin-

istration of AMPH in the prevention of fungal infec-

tions associated with hematological malignant di-

sorders4'549). Oral administration was effective, but

was insufficient for the prevention of fungal infec-

tions, except for some types of fungus. One of the

reasons is that AMPH was not administered in

VOL. 41 NO. 8 Prophylactic Use of Intravenous Amphotericin B in AML 883

sufficiently high doses in patients with acompanying

gastrointestinal disorders. Empirical administra-

tion of AMPH is a therapy worth considering in

patients with hematologic malignancy who remain

febrile in spite of administration of broad spectrum

antibiotics20•`22). Other authors have suggested em-

piric dosing guidelines for AMPH therapy14,23•`25).

However, the toxicity of intravenous administra-

tion of AMPH has limited its use to resistant syste-

mic infections. In one study, almost all patients

who had received intravenous administration of

AMPH at doses greater than 0.3mg/kg/day had

one or more adverse effects14). We may have to wait

for the development of a more effective and less

toxic drug, or devise a new administration method.

It is considered that among the available antifungal

agents, AMPH has a valuable effect, and thus

should be administered so as to minimize its adverse

effects and maximize its antifungal efficacy. We

therefore investigated the preventive effect of low

dose i.v. infusion of AMPH in patients with acute

leukemia. In the i.v. infusion group, the period of

fever was shorter, and the maximum CRP value

was significantly lower than in the oral administra-

tion group. The incidence of serious fungal infec-

tion in the i. v. infusion group was less (0 cases)

than that in the oral administration group (3 cases,

2 cases of suspected fungal sepsis, one of Aspergil-

lus pneumonia). Moreover, only a Candida spp.

was cultured in the i. v. infusiongroup. We there-

fore reason that administration of AMPH by i-v.

infusion, in addition to oral administration, is more

effective for preventing fungal infections than oral

administration alone. Adverse events in the i. v.

infusion group consisted of hypokalemia, renal

dysfunction, and drug eruption, but these were mild

and resolved shortly after the drug was stopped.

Measurement of AMPH concentration showed

that the serum concentration with oral administra-

tion of AMPH was insufficient for the prevention of

many kinds of fungal infection. For example,

Candida torulopsis, Corynebacterium neoformans,

Aspergillus fumigatus, and Aspergillus ni ger, with

respective MIC of 0.2-0.5ƒÊg/ ml, 1.25ƒÊg/ ml, 0.2

μg/ml, 1.9ƒÊg/ml and 1. 25ƒÊg/ml26), were not suffi-

ciently prevented with oral administration of

AMPH. This indicates that oral administration of

AMPH is not sufficient for prevention of invasion by

routes other than the gastrointestinal mucosa. The

serum concentration of AMPH with i. v. infusion in

addition to oral administration was 7.3 times higher

than that with the latter alone, which may prevent

the colonization of many fungi, including those

mentioned above. Some Aspergillus species, Mucor

species, and other fungi may be insufficiently inhib-

ited with this administration method. However,

these types of fungal infection are rare in the clincal

setting. We therefore conclude that the i.v. infu-

sion dose of 0.15mg/kg/day is appropriate for

prophylactic use, in view of serum levels and tox-

icity. The concentration of AMPH may be affected

by factors such as deoxycholation, ƒÀ-lipoprotein

and cholesterol levels, as well as the function of the

liver and other organs.

The diagnosis of fungal infections is difficult in

clinical practice. Methods which facilitate diagno-

sis of fungal infection include measurement of ƒÀ-D-

glucan, which was calculated from T-test and E-

test results in this study. The value of ƒÀ-glucan in

the i. v. infusion group was lower than in the oral

administration group. This finding also demon-

strates the advantage of prevention of fungal infec-

tions. We plan to perform further studies of other

diagnostic methods in the future.

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VOL.41 NO.8 Prophylactic Use of Intravenous Amphotericin B in AML 885

急性白血病におけるアンフォテリシンBの 少量点滴投与による

真菌感染の予防効果

竹下 明裕 ・新 庄 香 ・玉嶋 貞宏 ・大野 竜三

浜松医科大学第3内 科*

真菌感 染 の予 防 に関 す るamphotericin B(AMPH)の 少量点 滴静 注 の効 果 につ いて急性 骨

髄 性 白血 病 の28例 にお い て検 討 した。患 者 は地 固 め療 法 と強化 療 法 と してBHAC-DP療 法

を施 行 され た。BHAC-DP療 法 はEnocitabin(BHAC)250mg/日 を7日 間,Daunorubicin

(DNR)40mg/日 を3日 間,Predonisolone(PSL)30mg/日 を7日 間 施 行 した。AMPHは

点 滴静 注 群 と経 口投 与 群 に分 け,点 滴 静 注群 で はAMPH(0。15mg/kg/日)の 点 滴 静 注 を

AMPH(2,400mg/日)の 経 口投与 に加 えて41回 の治療 期 間 に投与 され た。経 口投 与群 で は

AMPH(2,400mg/日)が38回 の 治 療期 間 に 投 与 され た。無 熱 期 間,有 熱 期 間,CRP,血

沈,培 養結 果,副 作用,エ ン ド トキシ ンが2群 間 にて比 較検 討 され た。 点滴 静注群 で は有熱期

間が有 意 に短縮 され,重 症 真菌 感染 の頻 度(0例)も 経 口投与 群(3例)に 比 較 して少 なか っ

た。AMPHの 少 量点 滴静 注 に よる重 大 な副 作用 は認 め られなか っ た。

*浜 松市半田町3600